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Human Error Part 1: Communication Problems

Over the course of my career, I have worked as a direct employee in some of the largest companies in the automotive, security products, and medical device industries. Since starting my own consulting business 5 years ago, I have also had the opportunity to work with numerous small and medium size companies and hospitals as well as state and county government agencies. One common denominator across all of these organizations has been the susceptibility of every organization to human error.

I am currently developing a graduate level course on Human Error in industry and healthcare for Purdue University. The course will focus on identifying the root causes of human error in various processes and settings and will examine proven ways to minimize the opportunity for errors to occur. This is the first in a multi-part series of articles that will explain some of the ways and reasons that people make mistakes.

The subject of communication could be an entire series by itself. I am reminded of a cartoon I recently saw which showed two young kids and a dog. The first boy said that he had taught his dog how to whistle. The second boy listens for a moment then says that he can’t hear the dog whistling. The first boy responds “I said I taught him, I didn’t say he learned.”

"One common denominator across all of these organizations has been the susceptibility of every organization to human error."

Communication is the same way. For communication to take place, someone has to transmit “meaning” from their mind and it has to be received in the mind of one or more other people. The transmission could take place via spoken words, written words, diagrams, body language, etc. However, if the second person does not get and understand the intended message, then communication did not occur.

There are numerous reasons that might prevent the second person from getting and understanding what the first person wanted to share. The first person may only speak English and the second person may only understand German. Or, the first person may speak softly and the second person may not hear them. Likewise, the first person may speak at a normal volume and the second person may be deaf.

Even when words are exchanged in a common language, there can still be misunderstandings because of words used. For example, I enjoy hiking in Brown County State Park. I have been asked before “are there any poisonous snakes in Brown County?”. I could honestly tell them there are no “poisonous” snakes anywhere in Indiana, but there are some venomous ones.

If something is “poisonous” it means you would likely suffer harm if you ate it. That is not the case with snakes. I have seen rattlesnake meat for sale in a grocery store in Ohio. However, if something is venomous, it means you would likely suffer harm (possibly even death) if you were to be bitten by it.

There are Timber Rattlesnakes and Copperhead snakes in Indiana and both of these species of snake are venomous. So when I hear the question, “Are there any poisonous snakes” I assume the person is really concerned about whether there are any venomous snakes and they are simply using the wrong word to ask their question.

there are no “poisonous” snakes anywhere in Indiana, but there are some venomous ones.

This is a simple example but the principle behind it shows up frequently in corporate communications and work instructions. The person who writes the policy or work instruction may have one thing in mind but they may use the wrong words to communicate their intent. While many people may still understand the intended meaning, it creates an opportunity for error for someone who may not understand the intent and takes the instruction literally.

Another related communication error is a statement or question that contains a flawed assumption. This type of error is best illustrated in an old, classic cartoon that shows a man walking down the street who sees a young boy and a dog. The man asks the boy “does your dog bite?” and the boy says “no”. When the man attempts to pet the dog it bites his hand. The man then turns to the boy and says, “I thought you said your dog didn’t bite!”. The boy replies “that isn’t my dog.”

In this humorous example, who is responsible for the man getting bit? The boy honestly answered the question he was asked. The man made a logical assumption based upon what he observed but his assumption was wrong and it led to him getting bit.

In future articles I will explore some other common causes of human error including fatigue, complacency, judgment and distraction.